Medical Leave Annual Report

Susquehanna Conference Medical Leave Annual Report Form
Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Date Leave Began

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Charge Conference Membership
Conference Relationship
Last appointment
Church/Charge
District
Do you desire to resume full or part-time ministerial work at the next session of the Annual Conference?
Do you request an extension of your Medical Leave for the coming appointment year?
Person filling out this form
Other (Explain)
If someone other than the clergy person is filling out this form please provide the following information
Name
Phone
Format: (000) 000-0000.
Clergy Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If the clergy is unable to complete this form, Signature of person completing the form:
Signature of Person completing the form
Relationship
A COPY OF THIS REPORT WILL BE SENT TO the Bishop’s office, and the Conference Relations Committeechairperson. Requests for other changes of relationship (retirement, leave of absence, honorable location, etc.)should be directed to the CRC chairperson, bomcrc@susumc.org and your District Superintendent.
Should be Empty: